Seeking professional and clinical help can be the key to helping someone who may be contemplating suicide

On Dec. 13, 2022, dancer, actor and television personality Stephen "tWitch" Boss, best known for his work on "The Ellen DeGeneres Show," was found dead in a motel in Los Angeles from suicide. He was only 40 years old. Beloved by his fans, Boss—who was married with three children—always appeared happy, well-adjusted and outgoing. So, it came as a shock to the people who followed his career that he would die by suicide.

In 2020, 45,979 people died by suicide in the U.S., equating to one death by suicide every 11 minutes, according to the Centers for Disease Control. During that same time period, 12.2 million adults seriously thought about suicide and 1.2 million adults attempted suicide. Youth and young adults ages 10–24 years account for 14% of all suicides, and suicide is the third-leading cause of death for young people, according to the CDC.

But how does someone get to a point so low that they would take their own life? And how can someone that seemingly has it all fall victim to suicide, especially when they leave behind a grieving family to always wonder what went wrong?

Antonia Phillip, M.D., assistant clinical professor and board-certified adult and geriatric psychiatrist at VCU Health, was one of Boss' fans. Like others, she was shocked by the news.

Phillip, who specializes in adult and geriatric psychiatry, knows that some clients don't seek help at first because of the stigma sometimes associated with mental illness.

"The mind is the most complex organ in the body and also the head of the body," she said. "The brain is the thing that thinks and feels and controls the rest of you. We need it. Just as we take care of ourselves physically we also need to take care of our emotional, psychological being. Our culture is changing to accept that and promote it."

Phillip discussed the subject of suicide and suicide prevention in an interview with VCU News.

What leads someone to suicide?

That's a tough question because it is usually multifactorial. There might never really be one answer that leads someone to suicide. A lot of people experience a history of trauma, physical and mental abuse, sexual abuse or are exposed to violence in some way, who have a history of suicide in their family at a young age—they are more likely to repeat violence and in this case, violence toward themselves as suicide. In some cases, patients may even be receiving treatment. However, enduring emotions like depression, anxiety or other mental illness—whether clinical or otherwise chronic—can lead to suicide when stressors arise and the person can no longer bear it.

Change in a person's life can also be a trigger. Change such as when a loved one passes, losing a job, getting a divorce—to name a few—and difficulty adjusting to these changes can increase psychological and emotional stress, leading someone to suicide. In addition, people who engage in substance abuse, particularly alcohol, and people who have access to firearms are more at risk to suicide.

Altogether, when someone is led to suicide, in that moment of time, he or she feels hopeless or some despair about the future. Imagine the presence of being in a dark hole where you can't see anyone, can't see a future, can't problem solve but instead feel immense emotion like depression with no determined way out of that feeling or situation. That is hopelessness and a person may consider the solution is to self-destruct.

How can someone appear to have it all, be happy and well-adjusted and die by suicide?

One in five people in America will experience a mental health episode in a given year. We don't recognize that a lot of people are hurting mentally and emotionally. Also, our perception of people is not always accurate. We can put on a mask, so to speak, when we need to. Typically, people who die by suicide are probably suffering from some type of mental illness, but they are not able to communicate their pain for any reason. They may not know how to describe it or discern what it is. Others may identify what it is but choose not to manage it and just try cope. They will appear happy and do things to overcompensate, like being extra social and humorous, but inside many people are struggling with a mental illness.

There are multiple other reasons that could distract someone away from getting help. Someone may think, "I have it all, a beautiful home, a wife and kids, I make money. I shouldn't be depressed. Why do I feel this way? I am so embarrassed. I feel guilt and shame." Add emotional conflicts like these on top of depression, for example, and it snowballs, soon becoming a bigger beast. Usually, people who are depressed can't function academically or professionally, but some people can. A lot of the population are high functioning and so appear well-adjusted but are inwardly depressed. It can also be a genetic predisposition—mental illness. These and more can explain why some people who appear happy die by suicide. There is usually something there under the surface that is not doing well. They appear happy but underneath it all, something negative is brewing.

What is a mental illness?

Mental illness can refer to multiple conditions that affect us emotionally, psychologically and can include different diagnoses or disorders like depression, anxiety, phobia, adjustment disorder, bipolar disorder, acute stress disorder, PTSD, eating disorders like anorexia, sexual disorders and the list of possible disorders goes on.

What are outward signs that someone is contemplating suicide?

Detachment, withdrawal, substance use and abuse, particularly alcohol, giving away items, especially personal items, not taking care of themselves anymore, missing appointments, being lackadaisical about their health, not taking prescribed medications. They could be engaging in high-risk behaviors or have a preoccupation with death or dying that is not usual for them. Someone who is contemplating suicide may make suicidal statements like, "I want to die, or I want to kill myself." If this is the case, one can ask further questions of that person. Ask them to tell you more, actively listen and if there is any concern the person is actively suicidal, get them care. Call 911.

What are the hidden signs that someone is contemplating suicide?

Mood changes. Someone who has a known mental illness, such as anxiety or depression, and is known as struggling emotionally but then suddenly appears different. That's to say, for example, they suddenly appear to be very happy or joyful. That could be a sign they are contemplating suicide. There are clinical cases of patients whose families or friends may report "we are doing so good" but then took their own lives. On the other hand, someone could have worsening mood. Perhaps they appear more irritable or have what we term psychomotor agitation (a state of restlessness and anxiety that results in repetitive and unintentional movements). Continue to monitor mood changes, even positive ones. Ask questions, be more present. Provide care, concern and support to help prevent a suicide that someone may be contemplating.

Do people that die by suicide consider beforehand what it will do to their families?

I personally believe a person with a mental illness diagnosed or undiagnosed who has died by suicide was thinking "the world would be a better place without me." They are not well. They are not in their normal state of mind. They can't bear the emotional pain and psychological turmoil. They not only feel bad, but think they are bad. I truly believe they think they are doing better for others as well when they die by suicide. When they are down in that dark hole, they are unable to see or feel supported. But that is not the truth of the matter.

What are some of the ways people can help someone they believe is contemplating suicide?

If you or someone you know is having thoughts of suicide or are verbalizing suicidal ideations, call 911 or call or text 988 (the 988 Suicide and Crisis Lifeline). You can also visit 988Lifeline.org. There are always professionals and clinical providers available no matter the day or time. At VCU, you can call 804-828-6200 to reach University Counseling Services. There are multiple other crisis lines as well in Virginia.

If you know someone that is presenting signs of being high risk for suicide, tell them you are there. That you are open to listen. Encourage the person to feel safe to speak to someone whether a family member or a professional about how they are feeling. Monitor them until a health care provider or team can get to them. Depression is the inability to problem solve, a feeling of helplessness and loneliness. By showing support, you help someone who may be feeling this way.

Also, have a safety plan if there is a history of suicide in the family. Knowing what's best and what steps to take to help a friend or family member can be critical.

Make sure that weapons like firearms are not easily accessible. Hide medications and get sharp objects out of reach. Take out all pesticides and dangerous chemicals in the home.

In severe cases where supervision at home is acceptable for a person with passive suicidal ideation, and this is usually with children or adolescents, a parent or guardian can even monitor the person by taking the hinges off the door of their room for easy visibility and to reduce feelings of loneliness.

These are all some ways people contemplating suicide may be helped but always check in with your loved ones no matter how they appear.

If someone is thinking about suicide, what should they consider to help reverse those thoughts?

I like to remind patients that emotions can go up just as much as they go down and often are self-perpetuating. What's more is suicidal thoughts may not always be as obvious as "I want to die." If you or someone you know are having thoughts like that or even more subtle like, "Life is not worth living," or "I need a way out," or "I can't take this anymore," you can try to counteract those thoughts and influence the emotion with the following:

• Take 10 deep breaths being mindful of the breath, focusing the mind on each breath by counting quietly in your head, feel the breath filling your lungs and belly with air. Hold the breath for four to five seconds and the slowly release for six seconds while repeating peaceful words or phrases like "Everything will be OK" or "Stay calm" in your head. This exercise of mindfulness helps to slow the breathing and reduce anxiety or stress that one may be feeling physiologically.
• Start a gratitude journal. Writing at least three to five things you are grateful for is a simple exercise which produces endogenous dopamine that can improve one's emotional state. It also helps to refocus the thoughts onto more positive things.
• Be nonjudgmental with yourself. Check the facts as sometimes thoughts or emotions may be an interpretation of events but not the actual truth of a situation. This may include speaking to someone like a behavioral health clinician about it. Maintaining a therapeutic relationship with a counselor is an important adjunctive treatment for improving mental health.
• Repeating several phrases of affirmation, such as "It is enough to do my best," "Every day is a fresh start," and "This may be challenging but I can get through anything especially with the right help," can create hopefulness and boost problem-solving abilities.
• Refocus attention since when you are distracted, emotions can change. Plan pleasant events. For example, listen to music or watch a movie, draw and color, go out for walks in a safe time and manner, or exercise, watch funny videos, place a cold compress or ice at the nape of the neck, to name a few.
• Meditate on positive emotions. For instance, when you're feeling sad, try to think about what joy feels like, looks like, sounds like. What are you doing when you feel joy, etc. Immerse yourself onto a more positive emotion.
• Call a trusting and supportive friend or loved one, or call a help line.

Every life can be experienced as worth living. As psychologist Marsha Linehan describes, building a life worth living takes time and patience.